One nurse’s story: My father died of a heart attack at age 39, and our mother raised my siblings and me. We were all close to mom; however, as the oldest she and I had a special bond. At age 46 she had undergone a mitral valve replacement and her aortic valve was replaced about 9 years later. She had survived a cardiac arrest and pulmonary artery rupture. When she was hospitalized with dehydration and acute kidney injury, we believed she would spend some time in the hospital and be discharged. Her kidney function improved with fluids, and her output was carefully monitored with a urinary catheter. She had a history of atrial fibrillation and her rate control medications were held. One day, her temperature soared to 102.8 F and her heart rate increased to 130 beats per minute. She developed sepsis, which placed further stress on her pulmonary and cardiovascular system. In June 2001 my mother died from complications related to a catheter associated urinary tract infection. She was 61 years old and I still miss her.
“It’s just a urinary tract infection. It happens sometimes.” We’ve all heard those words, spoken by both physicians and nurses. On the surface, it’s a seemingly simple problem, to be remedied with a few doses of an antibiotic, paling in comparison to life-threatening conditions such as respiratory failure or cardiac bypass surgery. However, catheter-associated urinary tract infections (CAUTI) can be just as deadly.
A widespread problem
Even though the morbidity and mortality of CAUTIs is low compared to other hospital-acquired infections, the high use of indwelling urinary catheters causes a large number of urinary tract infections and deaths. In fact, CAUTIs are the most frequent healthcare associated infection, accounting for 30 % to 40% of infections in hospitalized patients according to data from the Centers for Disease Control and Prevention. It’s estimated that more than 560,000 nosocomial urinary tract infections occur annually, causing significant morbidity, hospital expenditures, and increased length of stay. Mortality from CAUTIs is thought to exceed 13,000 deaths each year. Adherence to recommended infection control practices could prevent 380,000 infections and 9,000 deaths annually.
As a result of the morbidity and mortality linked with CAUTIs, the Joint Commission’s Patient Safety Advisory Group recommended development of a National Patient Safety Goal (NPSG) to focus on the need to follow evidence-based practices to prevent the problem. NPSG.07.06.01 became effective in January 2013 and addresses insertion, maintenance, and surveillance of indwelling catheters. In addition, CAUTIs are deemed a preventable complication by the Centers for Medicare and Medicaid Services (CMS) and associated treatment costs are no longer reimbursable.
Pathophysiology of CAUTI
The act of inserting a catheter results in bacterial colonization in the bladder at a rate of 3% per day. By the end of 1 week the catheterized patient’s risk of bacteriuria is 25%. After 30 days, 100% of indwelling catheters are colonized with bacteria. While not all bacteriuria causes symptoms to the patient, 10% to 24% of these patients will develop a symptomatic CAUTI.
The most common bacteria are from the gastrointestinal tract or skin and include:
- Enterococcus species
- Escherichia coli
- Staphylococcus aureus
- Enterobacter species
- Coagulase-negative staphylococci
- Pseudomonas aeruginosa
- Proteus mirabilis
- Serratia species
- Klebsiella pneumonia
- Candida species
In the hospital, pathogens can enter the urinary tract due to environmental contact or contact with hospital personnel. Hospital-acquired bacteria tend to be more virulent compared to community-acquired bacteria and are more often resistant to at least one antimicrobial agent. Bacteria enter the urinary tract during insertion, through the catheter lumen itself, or via contact between the outside of the catheter and the urethra. Sixty-six percent of CAUTI’s are due to bacterial entrance via the catheter-urethral interface. The remainder of CAUTI’s is associated with bacterial contamination due to manipulation of the catheter and drainage system.
The indwelling catheter provides a surface for microbial adhesion. Bacteria that enter the urinary tract produce various adhesions, such as hair-like projections to allow them to become firmly attached to the catheter wall. Once attached, the bacteria form biofilm by following the sequence of maturation, production of polysaccharides, and dispersion into the local environment. Biofilm promotes bacterial growth and reproduction and shelters the bacteria from destruction by antiseptics, antibiotics, and the host’s immune system. Bacteria in this protected environment communicate genetic information with one another, promoting antibiotic resistance and spread of biofilm to other surfaces of the catheter and urinary epithelium. Biofilm can be composed of one or multiple species of bacteria, depending on the duration of the catheter. These bacteria that live in the biofilm bind to the catheter’s surface, and are virtually impossible to destroy while the catheter is still in place.
The presence of a catheter also causes inflammation and trauma to the urethral and bladder neck mucosa. Both latex and silicone catheters promote the inflammatory response. If that isn’t enough to cause a CAUTI, inflammation and trauma to the urinary epithelium compromises the patient’s own ability to effectively fight bacteria in the bladder.
These physiologic changes result in signs and symptoms such as fever, suprapubic pain, changes in urine characteristics (for example, cloudiness), urgency, and elevated white blood cell count.
Treatment and management
In patients with bacteriuria, removing the catheter (and hence, the source of the bacteria) solves the problem. Antibiotic treatment for asymptomatic bacteriuria is not recommended, unless the bacteriuria persists at least 48 hours after catheter removal. Before initiating any antibiotic therapy, a urine culture must be obtained to identify the infecting organism and decrease the likelihood of antimicrobial resistance. The Infectious Diseases Society of America recommends the following evidence-based treatments:
- For symptomatic patients without bacteremia, 7 days of antibiotic treatment may be considered if symptoms resolve promptly.
- For patients with delayed response or with bacteremia, 10 to 14 days of treatment are recommended.
- Patients who are not severely ill may benefit from a 5-day course of levofloxacin.
- Elderly female patients who develop CAUTI without upper urinary tract symptoms may benefit from a 3-day antibiotic regimen after the catheter is removed.
- Treatment regimens for complicated CAUTI range from 7 to 21 days of antimicrobial therapy.
Only YOU can prevent CAUTI!
The Joint Commission and CMS have developed guidelines for prevention of CAUTIs. CMS identified seven evidence-based guidelines for preventing CAUTI:
Insert catheters only for appropriate indications. According to the CDC, as many as 25% of hospitalized patients have catheters, and not all of them are necessary. The CDC’s Healthcare Infection Control Practices Advisory Committee (HICPAC) recommends indwelling catheters be used for the following conditions:
- acute urinary retention or bladder obstruction
- accurate intake and output measurements in critically ill patients
- perioperative use—urologic procedures, prolonged surgical duration (should be removed in postanesthesia care unit), patients receiving large volume infusions or diuretics during surgery, need for intraoperative urinary output monitoring
- assist healing of open sacral or perineal wounds in incontinent patients
- prolonged immobilization (eg, unstable spine, multiple traumatic injuries)
- end of life comfort care.
The HICPAC guidelines state that catheters should not be used as a method of managing incontinence or for patient or nurse convenience.
Remove catheter as soon as possible. The Surgical Care Improvement Project was initiated in 2006 as a collaboration between The Joint Commission, CMS, Institute for Healthcare Improvement, and the American Hospital Association. One of the core measures is to remove urinary catheters on postoperative day 1 or 2. Length of indwelling time is the single most significant contributing factor in developing a CAUTI. The sooner the catheter is removed, the less chance of developing biofilm and bacterial colonization. Development of a nurse-driven protocol to remind physicians when catheters are no longer necessary has proven to decrease catheter prevalence.
Ensure only properly trained personnel insert and maintain catheters. Understanding the causes of UTI can help eliminate urethral trauma and bacterial transmission during insertion and bacterial colonization while the catheter is in place.
Use strict aseptic technique when inserting the catheter. Hand hygiene, sterile supplies, and proper technique all contribute to a decrease in CAUTI. Use of a catheter securement device prevents movement of the catheter in and out of the urethra, which keeps bacteria from being deposited in the bladder. Choosing the smallest effective catheter size decreases the incidence of urethral trauma during insertion.
Maintain closed drainage system. Use drainage systems with sealed catheter-drainage tubing junctions. Obtain urine specimens aseptically. If the system becomes disconnected or leaks, replace the catheter and collecting system using sterile equipment and aseptic technique. If the catheter must be irrigated to prevent obstruction (ie, postoperative prostate or bladder surgery), consider using a closed continuous irrigation system.
Maintain unobstructed urine flow. Ensure the tubing is not kinked and the collection bag remains below the bladder at all times. Do not place the collection bag on top of the patient while transporting. Empty the bag regularly using a clean container for each patient.
Use strict hand hygiene and standard precautions. Wear gloves as appropriate during manipulation of catheter or collection system. Do not use complex drainage systems (for example, antiseptic cartridges in drainage port). Clean the urinary meatus with soap and water during daily bath. Prevent contact of the drainage port with the floor or collecting container.
CAUTI Prevention Initiatives
The Hospital Research and Education Trust (HRET) developed 26 Hospital Engagement Networks (HEN) in 2011 to reduce hospital acquired conditions. Their mission was to develop learning collaboratives for hospitals, provide incentives and activities to promote patient safety, conduct training programs, provide technical assistance to help hospitals achieve quality goals, develop a system to monitor hospital progress, and identify high-performing hospitals. CMS awarded $218 million to begin the HEN, applying the Comprehensive Unit-based Safety Program (CUSP) model to disseminate the information and tools to hospitals.
Goals of On the CUSP: Stop CAUTI are to reduce mean CAUTI rates by 25% over 18 months, improve patient safety by sharing project tools, and promote statewide efforts to eliminate healthcare acquired infections. The benefits of participating in the state, regional, and national initiatives include ongoing coaching and training, access to tools that other organizations have found successful, and sharing of information and data. The ongoing coaching and required data submission helps maintain focus on the project, which is essential with the myriad of other initiatives in process.
One hospital’s success story
Community Hospital Anderson is a 207-bed hospital located in east central Indiana. The medical-surgical management team attended the HEN leadership conference in May 2012 and joined the On the CUSP: Stop CAUTI initiative through the Indiana Hospital Association in June of 2012. The team formed a multidisciplinary project committee with representation from all nursing units, quality management, and information technology. All nursing staff was educated on the CAUTI prevention bundle and the importance of reducing healthcare acquired infections. In addition, CAUTI prevention was incorporated into the medical-surgical department annual competency fair. Physicians are also required to document the appropriate reason for the catheter when it is ordered.
Another initiative was to have unit charge nurses complete an audit sheet every day that summarizes the results of the daily assessments that registered nurses (RNs) perform for each patient with a urinary catheter.
Daily Urinary Catheter Assessment Tool
If a patient receives an assessment score that indicates the catheter is no longer necessary the order set authorizes the RN to remove the catheter. If the patient is being transferred from the ICU or emergency department, the RN taking report asks the transferring nurse if the catheter can be removed before transfer.
As a result of these initiatives, prevalence of CAUTIs in our two medical-surgical units has been reduced by one-half, and we have not experienced a CAUTI in more than 500 days.
It’s up to you
Catheter-associated urinary tract infections, while traditionally appearing benign, can have devastating consequences for our patients. CAUTI prevention requires diligence, perseverance, and assertiveness in providing the best patient care. With teamwork, collaboration, and effective communication, we can avoid being “caught” in the CAUTI trap and save patients like the mother at the start of this article.
Terri Townsend is a medical-surgical staff educator and Lois Meeker is the medical-surgical clinical director for Community Hospital Anderson in Anderson, Indiana. Pamela Anderson is a nurse practitioner for CORVASC St. Vincent Physician Network in Indianapolis, Indiana.
Acknowledgement: The authors would like to dedicate this article to the memory of co-author Pamela Anderson’s mother, who was the subject of the introductory story.
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